The Trouble with Anesthetizing the Dead

Editor’s Note: Preparation of this issue has involved all of us on the editorial team in digging deeper into the topic of brain death than we ever have before, and the learning curve has been steep and relentless. Part of the process has been listening to the voices of physicians “in the trenches” who have also begun to ask difficult questions about brain death and its connection to vital organ transplantation.

Opinions we received were divided on the inclusion of this reflection. Some felt it was important to recognize that questions about brain death and the implementation of neurological criteria may not be as isolated or uncommon as we think; giving that voice in these pages validates that there is, at least in some quite legitimate quarters, increasing concern on the subject.

Others felt strongly that the response of this physician cast doubt on the validity of neurological criteria solely on the basis of emotional appeal. Those voices quite correctly pointed out that the issue of determining life and death has become complex and deserves thoughtful and lengthy discussion on the merits. I would like to have been able to include a reflection from another perspective, but we received none.

Even so, it is important to remember that how we express our thoughts or concerns may have unexpected effects on others. One commentator related a situation in which a priest misrepresented the current conversations about brain death, stating incorrectly that the Church is leaning away from the idea of transplantation. This caused a crisis in faith, and almost in treatment, for a family awaiting a transplant.

I believe this article necessarily makes us aware of the need in this situation not only to listen to the voice of our own well-formed consciences but to respect those whose own inner voice says, “This you may not do” or “This you may do,” especially when we agree on almost all of the facts necessary to make a decision. Ultimately, it is important to listen to different experiences like these, even when we disagree with them, are made uncomfortable by them, or do not quite know how to respond to them, for they are the voices of dedicated Catholic physicians striving to bring Christ to the bedside in sometimes difficult and confusing situations.

Barbara Golder

Editor in Chief

It was early in my career as a private practice anesthesiologist. On call one night, I was informed that there was a case—and that case would be an organ harvest. Confused, I made a query and had it confirmed—they needed me to conduct an anesthetic on the organ donor.

A number of questions entered my mind: how does one conduct an anesthetic for this type of case? Are there certain blood pressure requirements, ventilation parameters, unusual drugs that need to be given? But the paramount question flashing across my brain was “Why does the donor need an anesthesiologist if he is dead?”

I mean, he is dead, right? Isn’t that what “brain death” means? I had never given much thought to brain death and organ donation. It just seemed a noble thing to do and a way to give life to others in an otherwise devastating situation. What’s the harm of donating one’s organs if you are dead? But this was different. I was personally going to be involved in it. It brought to mind some questions I had either never considered or glossed over. It was, at best, uncomfortable—and it remained uncomfortable.

During that case, and a few others over the ensuing years, I learned what I had to do. First, I had to provide anesthesia to the brain-dead organ donor in a virtually identical fashion to that which I provide for other critically ill patients. It turns out that brain-dead patients react to scalpels and electrocautery similarly to my other patients. Without adequate anesthesia, they become tachycardic and hypertensive. Perhaps even more bothersome was the fact that I had to administer paralytics to prevent our organ donors from moving during the case. I needed to have vasoactive drugs on hand to optimize hemodynamics and maximize organ perfusion. In short, it was similar to so many anesthetics we conduct for critically ill patients. But there were also stark differences, not the least of which was the fact that our efforts were not being put forth for the benefit of the patient on the table but rather for other patients in need of organs for transplant.

While my experience may not be universal, some of the differences were a bit disconcerting. The first thing I noticed was the normal respect for the patient seemed to be missing from the room. Part of this may be that harvest teams are almost invariably from outside institutions and organ procurement companies. They travel about harvesting organs routinely and seemed, at least to me, unconcerned with the organ donor as a person. Perhaps everyone simply considered the patient on the table to be gone, so they acted consistently with that. But the joking, the music, the conversation—it all seemed so out of place. I thought, “Even though this patient is dead, he or she deserves some respect.” This was, even if noble, a somber business. From cutting out and removing the heart, lungs, and liver to the later harvest of corneas and replacing long bones with the equivalent of broomsticks, the entire sequence was somewhere between disturbing and horrific.

The biggest difference of all was that my entire mission had been turned on its head. The patient on the operating table was, in fact, not the patient at all. He was not the one to whom we have sworn to “do no harm.” In effect, our patients were all the potential recipients of the organs. My new duty was to preserve the organs as well as possible until the removal of the heart—and then to simply shut off the ventilator and monitors, walk out, and eventually collect my rather lucrative fee for assisting. The normal dynamic of physician helping patient was absent; I felt like the temporary caretaker of an “organ farm,” one to be harvested with my assistance.

This experience was jarring, and I dreaded any further organ harvest assignments after the first few. These cases felt like a gross alteration in mission; they went against everything I had trained for and did on a daily basis. It is one thing in theory but quite another in practice to switch gears and “anesthetize the dead.”

To make matters worse, I was personally involved in at least two cases where proper protocol and criteria for declaring “brain death” were not applied. In one case, we discovered the patient had paralytics on board in the intensive care unit during an apnea test. We reversed the paralytic, and it became clear that the patient, while critically ill, was not dead. In another instance, I could find no documentation that proper testing had been done at all; I insisted on conducting my own makeshift apnea test in the operating room before I let them proceed. This ruffled a few feathers, but I stood my ground. This was the last harvest I participated in; I refused from that point on. My comfort with assisting with these cases, even accepting the concept of brain death, was tenuous at best. The realization that the application of brain death criteria was variable and, sometimes unreliable, was a bridge too far.

Refusing to participate in organ harvests was unheard of, and certainly risked my job, but that is a discussion for another time. Suffice it to say there are consequences to questioning the status quo regarding the harvest of organs from patients declared dead by neurologic criteria.

These experiences spurred me to learn about brain death. What is it? What does the Church say about it? I read about the Harvard Criteria, the Uniform Determination of Death Act, the President’s Council on Bioethics, and the rationale behind the idea of brain death. I read what the Catechism says, what John Paul II said, and more. It’s enough to make your head spin. In my observation, very few people have given it much thought, and physicians are no exception. Amazingly, most of us “just do it” because it is apparently accepted by the medical community. It was certainly not taught well in my medical education, nor in that of virtually anyone I have spoken to on the subject. In fact, when it comes to brain death, it seems that no one really knows what it means and few have explored the literature to find out.

It turns out there are some people who profess to know what it means. I learned that “brain death” is an imprecise and confusing term that only serves to muddy the waters. What we are really talking about is the declaration of death using neurologic criteria. What neurologic criteria? The death, or loss of function, of the entire brain. The essential point is that death of the whole brain, as demonstrated by a variety of tests, which differ from place to place in their kind and implementation, is evidence that death of the person has already occurred. In theological/philosophical terms, this would mean the soul has left the body.

The rationale for making such a declaration is that the brain is the integrating force for the entire organism. By this reasoning, once the brain ceases to function, the body, though perhaps preserved warm and pulsatile temporarily, will inevitably disintegrate. This opinion is held and defended by orthodox Catholic theologians for whom I hold great respect. There are a few problems, however, and they have spurred in me a deeper reflection rather than simple acceptance.

First, I found it disturbing that the invention of “declaration of death by neurologic criteria” was temporally associated with the newfound success at transplanting vital organs. Previous to this, these same patients would have the extraordinary means (usually a ventilator) removed, allowing them to be declared dead the old-fashioned way. But old-fashioned death, the cessation of cardiorespiratory function, renders organs nonviable in short order.

I then learned of the work of Alan Shewmon and others who contend that this idea of the brain being the sole integrating force of the organism has not stood up to scrutiny over time. They are convincing enough that the President’s Council on Bioethics reconvened in 2008 in order to reexplain the reasons for declaring that these people are dead. It is difficult, at least for me, to escape the idea that the affirmation of death by neurologic criteria was a preordained conclusion searching for a rationale. We need transplantable organs after all.

As a Catholic physician, I am left attempting to span the abyss between two worlds. On the one hand, the Catholic Church and her sure guidance in matters of faith and morals. She has declared that organ donation is noble, including vital organs once the patient is dead. She also declares that deciding when a person is dead is the competency of physicians (and not the Church). If physicians say the patient is dead, we assume the soul has left the body and it is licit to harvest organs for the good of others. John Paul II famously said that such a construct “…does not seem to conflict with the essential elements of a sound anthropology.”

In the medical/transplant world, we have patients with profound brain injury, many meeting criteria for whole brain death. We also have a need for organs for transplant. These are patients who seem certain to die anyway, even under conventional measures of death. We have an alternative way to declare a patient to be dead, that of death by neurologic criteria. Therefore, it is licit to take their organs if consent has been given.

This paradigm is widely if not universally accepted. Confusion may reign in some of the details, but virtually everyone focuses on the great good being done for the recipients. Of course, this is a utilitarian/proportionalist argument; as such, it is unacceptable from a Catholic perspective. But the proportionalist mind-set is dominant in medicine and society, and the Catholic physician seems to have Church approval to be involved in organ procurement and transplantation.

This tenuous alliance is held together by the “dead donor rule,” whereby a person must be dead to donate organs otherwise necessary for life. The dead donor rule itself is now under assault by those who contend it is legitimate to take organs from the terminally ill or those who consent to death by vital organ removal. For the Catholic, however, the dead donor rule is essential. While it remains, we are left with the following analysis: the Church says, “This is OK as long as the patient is dead. But the doctors get to say if he/she is dead.” The doctor says, “The Church says it’s legit.” But the Church is basing its decision on the opinion of the doctors whose very rationale for inventing the neurologic criteria includes the need for organs for transplant.

Straddling this abyss is…me, and others like me. In my case, having a modicum of instruction over the years in medicine, anesthesiology, philosophy, and theology, I cannot take refuge in ignorance. I must confront the disturbing facts. Things are changing rapidly, but for the Catholic, the “dead donor rule” is a must. Even with that, John Paul II says, we must have a “moral certainty” that the patient is dead. Based on what the medical world told him at the time, there didn’t seem to be a contradiction with sound anthropology. But we have more and better information now, and the questions that remain are significant and disturbing: is the patient who meets neurological criteria dead or merely in the process of dying? Or is he or she simply a person with a profound neurologic injury? Are we willing ourselves to believe he or she is dead, for noble reasons, despite the evidence before us? Does brain death really mean the soul has left the body?

I still don’t have certainty about whether a person without function of the whole brain is dead. I have devised and heard reasonable arguments to support and refute that position. For now, the Church has said it is acceptable, predicated on medical opinion, although I’m concerned this was based on incomplete or faulty information. I would never condemn a person acting on this approval in good faith. By the same token, I decline to participate in procuring organs from patients declared dead by neurologic criteria, and I expect my decision to be respected as well.

A long time ago, I learned that we are not to shoot into a bush while hunting if we are unsure whether there is a deer or another hunter in the bush. There is reason to question whether that is what we have been doing. Perhaps by reexamining this issue now, we are attempting to shut the barn door after the horse is out. But our duty is to Truth. These are hard questions, but they are questions worth asking. After all, these are not horses we are talking about. They are persons. And there are more of them.